Ambitious Predictions as Yusuf Preaches Prevention

April 20, 2011

April 18, 2011 (Geneva, Switzerland) — Application of a few simple principles to the entire world's population could help eliminate cardiovascular disease by 2050--this is the ambitious prediction of world-renowned cardiologist and epidemiologist Dr Salim Yusuf (McMaster University, Hamilton, ON), who gave an honorary lecture at the EuroPRevent 2011 meeting here this past weekend, to great applause.

Summarizing the current approach to CVD prevention as "too little, too few, and too late," he referred to the fact that many preventive strategies and most treatments are not reaching the majority of people in the world affected by CVD and that interventions are being left until far too late in life.

"The future approach has to be focused on the entire population and on societal change; both these are needed, and we need large changes in multiple risk factors. If this happens, we can eliminate CVD from the entire world by 2050," he prophesized. "After all, CVD was not common in 1830, so why can't it now become uncommon by 2050? That is the challenge we all face."

Enough of Why, We Need How

Dr Salim Yusuf

Yusuf's lecture came on the last day of the EuroPRevent meeting; this year, the conference has taken full advantage of its Geneva location and the proximity to the European headquarters of the World Health Organization (WHO), the World Heart Federation (WHF), the United European Football Association (UEFA), and the International Olympics Committee (IOC), with many symposia run jointly in association with these organizations.  

One of the topics much discussed at the meeting is how environments will need to radically change in order to facilitate more physical activity among human beings, who have evolved for the most part from being active hunter-gatherers to being extremely sedentary. In a talk earlier in the week entitled, "Enough of why, we need more how," Dr B Kayser (University of Geneva, Switzerland) explained that humans are inherently idle: "It's not enough to know--given the choice of escaping physical activity, we will. We are genetically programmed for laziness and excessive intake."

He illustrated this with a photo of a number of people crowded on an escalator, next to which one or two brave souls were taking the stairs, and asked the audience where they thought it had been taken. "The annual meeting of the American College of Sports Medicine" was the answer, illustrating perfectly the point he was trying to make. In order to reverse these bad habits, modern environments, which he labeled "obesogenic and toxic," must be adapted so that healthy behavior can be made easier.

We are genetically programmed for laziness and excessive intake.

For example, he noted, escalators and elevators are often "copper and shiny" and centrally located in buildings, whereas stairs are "out of the way, made of concrete, and don't smell nice." Yusuf agreed, telling of how, in their building at McMaster, they have placed the stairs centrally next to a glass elevator, so that those riding inside can be seen and made to feel guilty: "We have shamed people into using the stairs," he observed. And Yusuf also wondered why everyone in the auditorium was sitting down. "Why aren't you standing or, better still, on treadmills set at a low pace?" he wondered. "We have to rethink the design of our buildings."

Other important issues to consider are walkable environments and availability of cycle paths to make cycling a realistic option for traveling about and commuting, said Kayser. Ironically, few meeting attendees appeared to avail themselves of the 100 free bicycles offered for use outside the convention center during the three days of the EuroPrevent meeting.

We have only one cardiology department--so not too many colleagues interfering. We have all the ingredients for prevention.

Another well-known cardiologist, Dr Roberto Ferrari (University of Ferrara, Italy), told the meeting he is devoting his future to a new project: to make his hometown "a city of prevention, a model for the 21st century."

Ferrari explained that Ferrara already has a head start: "We have 9 km of medieval wall, and the place is flat, so we are a city of cyclists. Also, we are the number-one producer of fruits and vegetables in Italy, we have a heavy fishing industry because we are on the banks of a river delta, and we have only one cardiology department--so not too many colleagues interfering. We have all the ingredients for prevention."

The future approach has to be focused on the entire population and on societal change; both these are needed.

Although just beginning, the project will entail surveillance of risk factors among the 131 000 inhabitants of Ferrara at sites around the town and advice on how to improve health, production of educational TV commercials and websites, working with the food industry to develop tasty but healthy food, and offering cooking lessons, among other things, he noted.

"We hope in 10 years to understand how and why people make the wrong decisions regarding diet and lifestyle," Ferrari observed.

And Yusuf told of a study he is working on, the Prospective Urban Rural Epidemiologic Study (PURE) covering 400 000 people in both urban and rural communities in numerous countries worldwide, which is examining societal influences on human health, with first results due to be reported later this year.

Epidemics require a broad strategy; we can't deal with countries one at a time.

"Epidemiology is nothing if you don't have diversity," Yusuf observed, adding that access to care in poor countries is "even more important than in developed countries." And the issues are not just cost related, he said, noting that physician inertia and cultural problems--whereby people often don't realize they have to take pills for life--contribute just as much to the problem. "This is the biggest epidemic the world has, and epidemics require a broad strategy; we can't deal with countries one at a time."

Prevention Must Begin in Childhood

Yusuf also stressed in his talk that the changes that lead to CVD begin in infanthood. "We often think of CVD as a disease of the middle-aged and elderly, but it's not. I believe the first three years of life are when risk factors develop," he said, citing findings from a project he is involved in called the FAMILY study, which shows that blood pressure and lipid levels, while quite low in newborns, are nearer to the levels seen in adulthood even by the age of one. "If we can reduce risk factors early in life, the impact will be much greater. That is the future."

I believe the first three years of life are when risk factors develop.

There were numerous presentations throughout the meeting about ways to try to improve diet and encourage physical activity among children and teenagers, with educational programs set in schools and initiatives developed together with football teams across Europe. The latter was the subject of a whole symposium, held with UEFA, in which delegates heard about some of the best examples of using soccer as a platform to encourage children to eat healthily and take regular exercise. This includes the "something to chew on" campaign by Manchester United football club in the UK and the "Muuvit" program, which a number of football teams in Germany, Austria, and Switzerland have been using to promote healthy lifestyles in schools.

The children's view is that they want to play, they want to have fun.

Key to the success of such programs is ensuring that they are entertaining, said one speaker, Dr Susi Kriemler (Institute for Sport and Physical Education, Basel, Switzerland), in her talk on physical-activity promotion in schoolchildren. "The children's view is that they want to play, they want to have fun," she observed.

Sport is also an excellent way of involving adults in physical activity, and sports cardiology was one of the many themes of the EuroPRevent meeting, with a variety of presentations on many aspects of this field.

Luminita Sanda

Marrying the topic of sport and smoking cessation was a fascinating account of the work involved behind the scenes to make the Beijing 2008 Olympics smoke-free, in a country where smoking is still a huge problem.

"We can't say the Beijing Olympics was completely smoke-free; there were some violations. But there was a change in attitude among physicians and a change in social norms; it's a wave effect," Luminita Sanda (Tobacco Free Initiative, WHO, Geneva, Switzerland) told the meeting. And, "several of China's other Olympic cities have followed Beijing's lead and become smoke-free--for example, Shanghai," she noted.

Cardiologists Shy Away From Advising Patients on Smoking Cessation

Dr Phillip Tønnesen

Meanwhile, Dr Phillip Tønnesen (Gentofte Hospital, Copenhagen, Denmark) discussed smoking-cessation strategies in patients with cardiovascular disease. There are, he said, "relatively few studies in CVD patients with smoking-cessation products, but smoking is the most powerful risk factor." Also, "many physicians are afraid of using nicotine-replacement therapy, with the concern being that it might harm the heart, but that is not the case," he stressed.

The three smoking cessation-products available, nicotine-replacement therapies, sustained-release bupropion, and varenicline (Chantix/Champix, Pfizer) are effective, in combination with counseling, to increase the quit rate, he noted. "We can have a huge effect on mortality by getting patients to quit smoking," he urged. He held up the British National Health Service as a "great example" of a successful smoking-cessation program. There, it was recognized that smoking cessation was the most cost-effective intervention in medicine, "and they developed smoking-cessation units for every 150 000 inhabitants; counseling for smoking cessation is free, as are all the therapies designed to aid people in their attempts to quit."

To heartwire Tønnesen commented: "I think there should be formal, short education courses for cardiologists in smoking cessation. It's my experience that knowledge about smoking-cessation products is negligible, and often the patients know more about it than the doctor. If cardiologists get this knowledge, they know they have a key role, and I believe most would intervene. They should know about the drugs they can prescribe and then refer to a formal smoking-cessation program."

For patients, the message is "much stronger" if it comes from the cardiologist, he added; "it should be emphatic, but not scolding," with the recognition that smokers are first and foremost nicotine dependent, he said, displaying a photograph of a man with a cigarette stuck inside his tracheotomy pipe to illustrate the lengths that some people will go to in order to smoke when they are addicted. Unsurprisingly, says Tønnesen, doctors who are smokers themselves are much less likely to intervene in the form of promoting smoking cessation; "we know this from several surveys in Europe."

Hope That Workplace "Wellness Schemes" Will Take Off

Smoking cessation will certainly be part of what the European Association for Cardiovascular Prevention & Rehabilitation (EACPR) hopes will be a growing trend for people to receive advice on improving lifestyle at work, with the introduction of more and more workplace wellness schemes. The organization is launching the "Fit for Future" (3F) program, which, although still in the pilot stages, will ultimately aim to help companies standardize such schemes, attendees were told during a symposium on the subject.

Through data collection and analysis, the 3F program will test different methodologies and assessment tools, so that those found to be most effective can be reproduced and used throughout Europe, and those companies who offer excellent corporate wellness schemes will be given an internationally recognized mark of approval.

And in a move designed to encourage attendees to get their risk factors assessed, the EACPR made the so-called "orange bus" available for free for two days outside the convention center in Geneva. The vehicle, from the Ligue Vaudoise Contre Les Maladies Cardio-vasculaires and the Ligue de la Santé, travels in the western regions of Switzerland and stays for a few days in small towns. A professional team offers blood tests, risk assessment, and personal advice to improve cardiovascular health. An employee told heartwire the usual charge for a visit is 30 SwF ($34.00), which she said is "considerably less" than the cost of a doctor's visit in Switzerland. She said some people were returning for the seventh time, and they had been able to see real improvements in their risk factors. Another orange bus visits workplaces, she said, and in those cases, the company pays for the assessments.

And finally, the meeting drew to a close with the obligatory presentations on how chocolate and yoga can help in CVD prevention and how dance and music play a role. For the four EuroPRevent attendees who got up on stage to play in the jazz band at the closing ceremony, this was a no-brainer.

WHO Tobacco Free Initiative